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07-30-'11 16:20 FROM-Buckinham Property +559-452-8249 T-731 P0001/0001 F-463 I ,� APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY Anti-Entrapment Devices and Systems DATE' for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each Pump or multi le Pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1.and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information �I Facility Name: �_ `g Aoc r �f f Pool Identificationif more than 1 ( pooUspa at site): Facility Address: 9 [ ,C City; St:1 r ZIP: 997 l Owner Name:.l' Owner's Phone Number. Y Owners Address)( City„[� Zip X Pool constructed on or after J nuary 1,2010?: ❑ YesNo Pum Information Lt/ - PooL - Recirculation Pump p Jet/Booster Pump Make/Model /g / Do H.p /. Make/Model H_P O Other Pump: ❑ Feature pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Except Skimmer Erivalizer Lines Manufacturer of approved drain cover: Model Number. .S17x Install date GPM rating:Floor?.nr)Wall Installed on *Floor ❑ Wall Manufacturer of approved drain cover; Model Number. Install date GPM rating:Floor Wall Installed on O Floor 0 Wall Main drain/Jet suction pipe size is inches. Check One: O Split main drain(s)(Minimum 3 ft.between Covers, hydraulically balanced and symmetrically plumbed) O Single drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) Single drain-Not unblockable (one of the following secondary devices required: safety vacuum release system,suction limiting vent system, gravity drainage system, auto pum shut-off system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed:�%7.�"_ Install date Manufacturer of approved device: n /r. Model/Part Number. Safety vacuum release system bears the followin performance standard markings:❑ATSM F2387 0 ASME/ANSI standard A 112.19.17 Skimmer EgualizerLine(s) ,r Manufacturer of approved suction fitting: /t/� Model Number: �~ Install date GPtvi rating:GPM ratings FlborWaIF= Installed on 04Flesr-51-^Wall Skimmer equalizer iine(s)pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S IN6TALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license# R29_V ,q- with classification'�'6/ ..zsor a California State Professional Engineer license# with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that it I improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health i£Safety Code Section 116064.2. ContractoyEngineerName; za& �•�Jy�r±c Company Name: � �,np,o� Company Address: '�'—" Com' /^ii S',t!(! Slate: '°�< /'� Zip Code: Contractor/Engineer Phone Number: �SS aIYCiG r �Ceti Phone Number: rug) .3S/-X&L. Contractor/Engineer FAX.Nuuumber.�fjg) Z.92.-�� Email: � - 1-611- 11/ a�-�f�f o ri b '6 - 1 l Contractor/Engineer nam RINT) C9�r c or/Enginemw4lame( NATURE) Date For a complete text of the law,visit: httP:/rnfo.sen.ca.govlpub/OJ-10/bill/asm/ab_I001-1050/ab_1020_bill-20091011_chaptered.pdf 1 ? i ' ; ,J . :gat'